Provider Demographics
NPI:1154017960
Name:MCKIM, NANETTE NELL
Entity type:Individual
Prefix:
First Name:NANETTE
Middle Name:NELL
Last Name:MCKIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 SPRING FOREST CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6721
Mailing Address - Country:US
Mailing Address - Phone:260-257-9295
Mailing Address - Fax:
Practice Address - Street 1:2121 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5100
Practice Address - Country:US
Practice Address - Phone:260-426-5431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28115626A163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergencyGroup - Single Specialty